Health Maintenance Organization (HMO) Certificate of Coverage. Plan name: GA Silver HNOption /50 GAO

Transcription

1 Health Maintenance Organization (HMO) Certificate of Coverage Plan name: GA Silver HNOption /50 PPID: GAO Underwritten by Aetna Health Inc. in the state of Georgia HI SG HCOC GA 2018

2 Assistive Technology Persons using assistive technology may not be able to fully access the following information. For assistance, please call Smartphone or Tablet To view documents from your smartphone or tablet, the free WinZip app is required. It may be available from your App Store. Non-Discrimination Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability. Aetna provides free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, P.O. Box 14462, Lexington, KY (CA HMO customers: PO Box Fresno, CA 93779), , TTY: 711, Fax: (CA HMO customers: ), CRCoordinator@aetna.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at , (TDD). Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

3 Language Assistance TTY: 711 For language assistance in English call at no cost. (English) Para obtener asistencia lingüística en español, llame sin cargo al (Spanish) 欲取得繁體中文語言協助, 請撥打 , 無需付費 (Chinese) Pour une assistance linguistique en français appeler le sans frais. (French) Benötigen Sie Hilfe oder Informationen in deutscher Sprache? Rufen Sie uns kostenlos unter der Nummer an. (German) በ አማርኛ የቋንቋ እገዛ ለማግኘት በ በነጻ ይደውሉ (Amharic) للمساعدة في (اللغة العربیة) الرجاء الاتصال على الرقم المجاني (Arabic) Pou jwenn asistans nan lang Kreyòl Ayisyen, rele nimewo gratis. (French Creole) )Gujarati) ગ જર ત મ ભ ષ મ સહ ય મ ટ ક ઈ પણ ખર ચ વગર પર ક લ કર. (Hindi) ह न द म भ ष स यत क ल ए, पर म फ त क कर 日本語で援助をご希望の方は まで無料でお電話ください (Japanese) 한국어로언어지원을받고싶으시면무료통화번호인 번으로전화해주십시오. (Korean) برای راھنمایی بھ زبان فارسی با شماره بدون ھیچ ھزینھ ای تماس بگیرید. انگلیسی (Persian) Para obter assistência linguística em português ligue para o gratuitamente. (Portuguese) Чтобы получить помощь русскоязычного переводчика, позвоните по бесплатному номеру (Russian) Để được hỗ trợ ngôn ngữ bằng (ngôn ngữ), hãy gọi miễn phí đến số (Vietnamese)

4 Welcome Thank you for choosing Aetna. This is your Certificate of Coverage, or certificate for short. It is one of three documents that together describe the benefits covered by your Aetna plan for coverage. This certificate will tell you about your covered benefits what they are and how you get them. The second document is the schedule of benefits. It tells you how we share expenses for eligible health services and tells you about limits like when your plan covers only a certain number of visits. The third document is the group agreement between Aetna Health Inc. (Aetna) and your contract holder. Ask your employer if you have any questions about the group agreement. Sometimes, these documents have amendments, inserts or riders which we will send you. These change or add to the documents they re part of; When you receive these, they are considered part of your Aetna plan for coverage. Where to next? Try the Let s get started! section. Let's get started! gives you a summary of how your plan works. The more you understand, the more you can get out of your plan. Welcome to your Aetna plan. Notice: The laws of the State of Georgia prohibit insurers from unfairly discriminating against any person based upon his or her status as a victim of family violence. HI SG HCOC GA 2018

5 Table of Contents Welcome Page Let s get started! 4 Medical necessity and precertification requirements 11 Eligible health services under your plan 12 What your plan doesn t cover eligible health service exceptions and exclusions 45 Who provides the care 58 What the plan pays and what you pay 61 When you disagree - claim decisions and appeal procedures 63 Coordination of benefits (COB) 69 When coverage ends 74 Special coverage options after your coverage ends 76 General provisions other things you should know 83 Glossary 86 Discount programs 99 Wellness and other incentives 99 Schedule of benefits Issued with your certificate HI SG HCOC GA 2018

6 Let s get started! Here are some basics. First things first some notes on how we use words. Then we explain how your plan works so you can get the most out of your coverage. But for all the details this is very important you need to read this entire certificate and the schedule of benefits. And if you need help or more information, we tell you how to reach us. Some notes on how we use words When we say you and your, we mean both you and any covered dependents, if dependent coverage is available under your plan. When we say us, we, and our, we mean Aetna. Some words appear in bold type. We define them in the Glossary section. Sometimes we use technical medical language that is familiar to medical providers. What your plan does providing covered benefits Your plan provides covered benefits. Benefits are provided for eligible health services. Your plan has an obligation to pay for eligible health services. How your plan works starting and stopping coverage Your coverage under the plan has a start and an end. You start coverage after you complete the eligibility and enrollment process. To learn more see the Who the plan covers section. Coverage is not provided for any services received before coverage starts or after coverage ends. Your coverage typically ends when you leave your job. Family members can lose coverage for many reasons, such as growing up and leaving home. To learn more see the When coverage ends section. Ending coverage under the plan doesn t necessarily mean you lose coverage with us. See the Special coverage options after your coverage ends section. How your plan works while you are covered Your coverage: Helps you get and pay for a lot of but not all health care services. Benefits are provided for eligible health services. Generally will pay only when you get care from network providers. 1. Eligible health services Doctor and hospital services are the base for many other services; You ll probably find the preventive care and wellness, emergency services and urgent condition coverage especially important. But the plan won't always cover the services you want. Sometimes it doesn't cover health care services your doctor will want you to have. So what are eligible health services? They are health care services that meet these three requirements: They appear in the Eligible health services under your plan section. HI SG HCOC GA 2018

7 They are not listed in the What your plan doesn t cover eligible health service exceptions and exclusions section. (We will refer to this section as the Exceptions section in the rest of this certificate.) They are not beyond any limits in the schedule of benefits. 2. Providers Our network of doctors, hospitals and other health care providers is there to give you the care you need. You can find network providers and see important information about them most easily on our online provider directory. Just log into your Aetna Navigator secure member website at You may choose a primary care physician (we call that doctor your PCP) to oversee your care. Your PCP will provide your routine care, and send you to other providers when you need specialized care. You don t have to access care through your PCP. You may go directly to network specialists and providers for eligible health services. Your plan often will pay a bigger share for eligible health services that you get through your PCP, so choose a PCP as soon as you can. For more information about the network and the role of your PCP, see the Who provides the care section. 3. Service area Your plan generally pays for eligible health services only within a specific geographic area, called a service area. There are some exceptions, such as for emergency services and urgent care. See the Who provides the care section. Important note: If you have a dependent and they move outside of the service area, their coverage outside of the service area will be limited to emergency and urgent conditions for both medical and pharmacy services. 4. Paying for eligible health services the general requirements There are several general requirements for the plan to pay any part of the expense for an eligible health service. They are: The eligible health service is medically necessary. You get the eligible health service from a network provider. You or your provider precertifies the eligible health service when required. You will find details on medical necessity and precertification requirements in the Medical necessity and precertification requirements section. You will find the requirement to use a network provider and any exceptions in the Who provides the care section. HI SG HCOC GA 2018

8 5. Paying for eligible health services sharing the expense Generally, your plan and you will share the expense of your eligible health services when you meet the general requirements for paying. But sometimes your plan will pay the entire expense; and sometimes you will. For more information see the What the plan pays and what you pay section, and see the schedule of benefits. 6. Disagreements We know that people sometimes see things differently. The plan tells you how we will work through our differences. And if we still disagree, an independent group of experts called an external review organization or ERO for short, may sometimes make the final decision for us. For more information see the When you disagree - claim decisions and appeal procedures section. How to contact us for help We are here to answer your questions. You can contact us by: Logging on to your Aetna Navigator secure member website at Register for our secure Internet access to reliable health information, tools and resources. Aetna Navigator online tools will make it easier for you to make informed decisions about your health care, view claims, research care and treatment options, and access information on health and wellness. You can also contact us by: Calling Aetna Member Services at the toll-free number on your ID card Writing us at 1425 Union Meeting Road, Blue Bell, PA Your member ID card Your member ID card tells doctors, hospitals, and other providers that you re covered by this plan. Show your ID card each time you get health care from a provider to help them bill us correctly and help us better process their claims. Remember, only you and your covered dependents can use your member ID card. If you misuse your card we may end your coverage. We will mail you your ID card; If you haven t received it before you need eligible health services, or if you ve lost it, you can print a temporary ID card; Just log into your Aetna Navigator secure member website at HI SG HCOC GA 2018

9 Who the plan covers You will find information in this section about: Who is eligible When you can join the plan Who can be on your plan (who can be your dependent) Adding new dependents Special times you can join the plan Who is eligible Your employer decides and tells us who is eligible for health care coverage. When you can join the plan As an employee you can enroll: At the end of any waiting period your employer requires Once each calendar year during the annual enrollment period At other special times during the year (see the Special times you can join the plan section below) If you do not enroll when you first qualify for health benefits, you may have to wait until the next annual enrollment period to join. Who can be on your plan (who can be your dependent) If your plan includes coverage for dependents, you can enroll the following family members on your plan; (They are your dependents ;) Your legal spouse Your domestic partner who meets eligibility rules set by your employer and requirements under state law Your dependent children your own or those of your spouse, domestic partner The children must be under 26 years of age and they include your: - Biological children - Stepchildren - Legally adopted children, including any children placed with you for adoption - Foster children - Children you are responsible for under a qualified medical support order or courtorder (whether or not the child resides with you and whether or not the child resides inside the service area) - Grandchildren in your court-ordered custody - Any other child with whom you have a parent-child relationship HI SG HCOC GA 2018

10 Effective date of coverage Your coverage will begin after we have received your completed enrollment form. Depending on when you enroll, the start date will be either: On the date the contract holder tells us As described under Special times you can join the plan (later in this section) Dependent coverage will start: On your effective date, if you enrolled them at that time. Generally, the first day of the month based on when we receive your completed enrollment form, if you enrolled them at another time. See Adding new dependents and Special times you can join the plan for more information. Important note: You may continue coverage for a disabled child past the age limit shown above. See Continuation of coverage for other reasons in the Special coverage options after your coverage ends section for more information. You can t have coverage as an employee and a dependent and you can t be covered as a dependent of more than one employee on the plan. Adding new dependents If your plan includes coverage for dependents, you can add the following new dependents to your plan: A spouse - If you marry, you can put your spouse on your plan. - We must receive your completed enrollment information not more than 31 days after the date of your marriage. - Ask your employer when benefits for your spouse will begin: o If we receive your completed enrollment information by the 15 th of the month, coverage will be effective no later than the first day of the following month. o If we receive your completed enrollment information between the 16th and the last day of the month, coverage will be effective no later than the first day of the second month. A domestic partner - If you enter a domestic partnership, you can enroll your domestic partner on your plan. See Who can be on your plan (Who can be your dependent) section for more information. - We must receive your completed enrollment information not more than 31 days after the date you file a Declaration of Domestic Partnership, or not later than 31 days after you provide documentation required by your employer. - Ask your employer when benefits for your domestic partner will begin. It will be on the date your Declaration of Domestic Partnership is filed or the first day of the month following the qualifying event date. A newborn child - Your newborn child is covered on your health plan for the first 31 days after birth. - To keep your newborn covered, we must receive your completed enrollment information within 31 days of birth. - You must still enroll the child within 31 days of birth even when coverage does not HI SG HCOC GA 2018

11 require payment of an additional premium contribution for the covered dependent. - If you miss this deadline, your newborn will not have health benefits after the first 31 days. An adopted child - You may put an adopted child on your plan when the adoption is complete or the date the child is placed for adoption. Placed for adoption means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of the child. - You must complete your enrollment information and send it to us within 31 days after the adoption or the date the child was placed for adoption. - Ask your employer when benefits for your adopted child will begin. It is usually the date of the adoption (or placement) or the first day of the month following adoption (or placement). A foster child You may put a foster child on your plan when you have obtained legal responsibility as a foster parent. A foster child is a child whose care, comfort, education and upbringing is left to persons other than the natural parents. - You must complete your enrollment information and send it to us within 31 days after the date the child is placed with you. - Ask your employer when benefits for your foster child will begin. It is usually the date you legally become a foster parent or the first day of the month following this event. A stepchild - You may put a child of your spouse, domestic partner on your plan. - You must complete your enrollment information and send it to us within 31 days after the date of your marriage, declaration of domestic partnership with your stepchild s parent; - Ask your employer when benefits for your stepchild will begin. It is the date of your marriage, declaration of domestic partnership or the first day of the month following the qualifying event date. Court order You can put a child you are responsible for under a qualified medical support order or court order on your plan. - You must complete your enrollment information and send it to us within 31 days after the date of the court order. - Ask your employer when benefits for the child will begin. It is usually the date of the court order or the first day of the month following the qualifying event date. Inform us of any changes It is important that you inform us of any changes that might affect your benefit status. This will help us effectively deliver your benefits. Please contact us as soon as possible with changes such as: Change of address or phone number Change in marital status Change of covered dependent status A covered dependent who enrolls in Medicare or any other health plan HI SG HCOC GA 2018

12 Special times you can join the plan Federal law allows you and your dependents, if your plan includes coverage for dependents, to enroll at times other than your employer s annual open enrollment period; This is called a special or limited enrollment period. You can enroll in these situations when: You have added a dependent because of marriage, birth, adoption or foster care. See the Adding new dependents section for more information. You or your dependent qualify for access to new plans because you have moved to a new permanent location. You or your dependent did not enroll in this plan before because: - You were covered by another health plan, and now that other coverage has ended. - You had COBRA, and now that other coverage has ended. A court orders you to cover a current spouse, domestic partner or a child on your health plan. You or your dependent lose your eligibility for enrollment in Medicaid or a FEDVIP plan. You or your dependent become eligible for State premium assistance under Medicaid or a FEDVIP plan for the payment of your premium contribution for coverage under this plan. We must receive your completed enrollment information from you within 31 days of the event or the date on which you no longer have the other coverage mentioned above. However, the completed enrollment form may be submitted within 60 days of the event when: You lose your eligibility for enrollment in Medicaid or a FEDVIP plan Medicaid You become eligible for State premium assistance under Medicaid or a FEDVIP plan for the payment of your premium contribution for coverage under this plan Effective date of coverage Your coverage will be in effect based on when we receive your completed enrollment application: No later than the first day of the following month if completed enrollment information is received by the 15 th of the month No later than the first day of the second month if completed enrollment information is received between the 16 th and the last day of the month In accordance with the effective date of a court order An appropriate date based on the circumstances of the special enrollment period HI SG HCOC GA 2018

13 Medical necessity and precertification requirements The starting point for covered benefits under your plan is whether the services and supplies are eligible health services. See the Eligible health services under your plan and Exceptions sections plus the schedule of benefits. Your plan pays for its share of the expense for eligible health services only if the general requirements are met. They are: The eligible health service is medically necessary. You get the eligible health service from a network provider. You or your provider precertifies the eligible health service when required. This section addresses the medical necessity and precertification requirements. You will find the requirement to use a network provider and any exceptions in the Who provides the care section. Medically necessary; medical necessity As we said in the Let's get started! section, medical necessity is a requirement for you to receive eligible health services under this plan. The medical necessity requirements are in the Glossary section, where we define "medically necessary, medical necessity". That s where we also explain what our medical directors, or a physician they assign, consider when determining if an eligible health service is medically necessary. Precertification You need pre-approval from us for some eligible health services. Pre-approval is also called precertification. Your physician or PCP is responsible for obtaining any necessary precertification before you get the care. For precertification of outpatient prescription drugs, see Eligible health services under your plan Outpatient prescription drugs What precertification requirements apply. If your physician or PCP doesn't get a required precertification, we won't pay the provider who gives you the care. You won't have to pay either if your physician or PCP fails to ask us for precertification. If your physician or PCP requests precertification and we refuse it, you can still get the care but the plan won t pay for it; You will find details on requirements in the What the plan pays and what you pay - Important note when you pay all section. HI SG HCOC GA 2018

14 Eligible health services under your plan The information in this section is the first step to understanding your plan's eligible health services. If you have questions about this section, see the How to contact us for help section. Your plan covers many kinds of health care services and supplies, such as physician care and hospital stays. But sometimes those services are not covered at all or are covered only up to a limit. For example: Physician care generally is covered but physician care for cosmetic surgery is never covered. This is an exclusion. Home health care is generally covered but it is a covered benefit only up to a set number of visits a year. This is a limitation. You can find out about exclusions in the Exceptions section and about limitations in the schedule of benefits. We've grouped the eligible health services below to make it easier for you to find what you're looking for. Important note: Sex-specific eligible health services are covered when medically appropriate, regardless of identified gender. HI SG HCOC GA 2018

15 1. Preventive care and wellness This section describes the eligible health services and supplies available under your plan when you are well. Important notes: 1. You will see references to the following recommendations and guidelines in this section: Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention United States Preventive Services Task Force Health Resources and Services Administration American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents When these recommendations and guidelines are updated, they will apply to this plan. The updates will be effective on the first day of the plan year, one year after the updated recommendation or guideline is issued. 2. Diagnostic testing is not covered under the preventive care benefit. You will pay the cost sharing specific to eligible health services for diagnostic testing. 3. Gender-specific preventive care benefits include eligible health services described below regardless of the sex you were assigned at birth, your gender identity, or your recorded gender. 4. To learn what frequency and age limits apply to routine physical exams and routine cancer screenings, contact your physician or see the How to contact us for help section. This information can also be found at the website. Routine physical exams Eligible health services include office visits to your physician, PCP or other health professional for routine physical exams. This includes routine vision and hearing screenings given as part of the exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and it includes: Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents. Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: - Screening and counseling services on topics such as: o Interpersonal and domestic violence o Sexually transmitted diseases o Human Immune Deficiency Virus (HIV) infections - Screening for gestational diabetes for women - High risk Human Papillomavirus (HPV) DNA testing for women Radiological services, lab and other tests given in connection with the exam. HI SG HCOC GA 2018

16 For covered newborns, an initial hospital checkup. Bone density screening for osteoporosis Preventive care immunizations Eligible health services include immunizations provided by your physician for infectious diseases recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Well woman preventive visits Eligible health services include your routine: Well woman preventive exam office visit to your physician, PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes Pap smears and routine chlamydia screening tests. Your plan covers the exams recommended by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified illness or injury. Preventive care breast cancer (BRCA) gene blood testing by a physician and lab. Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the test results and evaluate treatment. Preventive screening and counseling services Eligible health services include screening and counseling by your health professional for some conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer. Your plan will cover the services you get in an individual or group setting. Here is more detail about those benefits. Obesity and/or healthy diet counseling Eligible health services include the following screening and counseling services to aid in weight reduction due to obesity: - Preventive counseling visits and/or risk factor reduction intervention - Nutritional counseling - Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease Misuse of alcohol and/or drugs Eligible health services include the following screening and counseling services to help prevent or reduce the use of an alcohol agent or controlled substance: - Preventive counseling visits - Risk factor reduction intervention - A structured assessment Use of tobacco products Eligible health services include the following screening and counseling services to help you to stop the use of tobacco products: - Preventive counseling visits - Treatment visits - Class visits Tobacco product means a substance containing tobacco or nicotine such as: - Cigarettes HI SG HCOC GA 2018

17 - Cigars - Smoking tobacco - Snuff - Smokeless tobacco - Candy-like products that contain tobacco Sexually transmitted infection counseling Eligible health services include the counseling services to help you prevent or reduce sexually transmitted infections. Genetic risk counseling for breast and ovarian cancer Eligible health services include the counseling and evaluation services to help you assess whether or not you are at increased risk for breast and ovarian cancer. Routine cancer screenings Eligible health services include the following routine cancer screenings: Mammograms including baseline Prostate specific antigen (PSA) tests Digital rectal exams Fecal occult blood tests Sigmoidoscopies Double contrast barium enemas (DCBE) Colonoscopies which includes removal of polyps performed during a screening procedure and a pathology exam on any removed polyp Lung cancer screenings CA-125 serum tumor marker testing, transvaginal ultrasound, and rectovaginal pelvic exam for woman age 35 and older who are at risk of ovarian cancer These benefits will be subject to any age, family history and frequency guidelines that are: Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration Prenatal care Eligible health services include your routine prenatal physical exams as preventive care, which includes the initial and subsequent physical exam services such as: Maternal weight Blood pressure Fetal heart rate check Fundal height Anemia screening Chlamydia infection screening Hepatitis B screening Rh incompatibility screening You can get this care at your physician's, PCP s, OB's, GYN's, or OB/GYN s office. HI SG HCOC GA 2018

18 Important note: You should review the benefit under the Eligible health services under your plan - Maternity and related newborn care and Exceptions sections of this certificate for more information on coverage for pregnancy expenses under this plan. Comprehensive lactation support and counseling services Eligible health services include comprehensive lactation support (help and training in breast feeding) and counseling services during pregnancy or at any time following delivery for breast-feeding. Your plan will cover this when you get it in an individual or group setting. Your plan will cover this counseling only when you get it from a certified lactation support provider. Breast feeding durable medical equipment Eligible health services include renting or buying durable medical equipment you need to pump and store breast milk as follows: Breast pump Eligible health services include: Renting a hospital grade electric pump while your newborn child is confined in a hospital. The buying of either: - An electric breast pump (non-hospital grade). Your plan will cover this cost once every 36 months. - A manual breast pump. Your plan will cover this cost once per pregnancy. If an electric breast pump was purchased within the previous 36 month period, the purchase of another electric breast pump will not be covered until one of these things happens: A 36 month period has elapsed since the last purchase The initial electric breast pump is broken and no longer covered under a warranty Breast pump supplies and accessories Eligible health services include breast pump supplies and accessories. These are limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment for the same or similar purpose. It also includes the accessories and supplies needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Family planning services female contraceptives counseling, devices and voluntary sterilization Eligible health services include family planning services such as: Counseling services Eligible health services include counseling services provided by a physician, PCP, OB, GYN, or OB/GYN on contraceptive methods. These will be covered when you get them in either a group or individual setting. HI SG HCOC GA 2018

19 Devices Eligible health services include contraceptive devices (including any related services or supplies) when they are provided, administered or removed by a physician during an office visit. Voluntary sterilization Eligible health services include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies. This also could include tubal ligation and sterilization implants. Important note: See the following sections for more information: Family planning services other Maternity and related newborn care Outpatient prescription drugs - preventive contraceptives Treatment of basic infertility HI SG HCOC GA 2018

20 2. Physicians and other health professionals Physician services Eligible health services include services by your physician to treat an illness or injury. You can get those services: At the physician s office In your home In a hospital From any other inpatient or outpatient facility By way of telemedicine Important note: Your plan covers telemedicine only when you get your consult through a provider that has contracted with Aetna to offer these services. All in-person office visits covered with a behavioral health provider are also covered if you use telemedicine instead. Telemedicine may have different cost sharing. See the schedule of benefits for more information. Other services and supplies that your physician may provide: Allergy testing and allergy injections Radiological supplies, services, and tests Physician surgical services Eligible health services include the services of: The surgeon who performs your surgery Your surgeon who you visit before and after the surgery Another surgeon you go to for a second opinion before the surgery Alternatives to physician office visits Walk-in clinic Eligible health services include health care services provided at walk-in clinics for: Unscheduled, non-medical emergency illnesses and injuries The administration of immunizations administered within the scope of the clinic s license Individual screening and counseling services that will help you: - In weight reduction due to obesity and/or healthy diet - To stop the use of tobacco products HI SG HCOC GA 2018

21 3. Hospital and other facility care Hospital care Eligible health services include inpatient and outpatient hospital care. The types of hospital care services that are eligible for coverage include: Room and board charges up to the hospital s semi-private room rate. Your plan will cover the extra expense of a private room when appropriate because of your medical condition. Services of physicians employed by the hospital. Operating and recovery rooms. Intensive or special care units of a hospital. Administration of blood and blood derivatives. Radiation therapy. Cognitive rehabilitation. Speech therapy, physical therapy and occupational therapy. Oxygen and oxygen therapy. Radiological services, laboratory testing and diagnostic services. Medications. Intravenous (IV) preparations. Discharge planning. Services and supplies provided by the outpatient department of a hospital. Anesthesia and hospital charges for dental care, if: You are 7 years old or younger or are developmentally disabled. A successful result cannot be expected from dental care provided under local anesthesia because of a neurological or other medically compromising condition. You have sustained extensive facial or dental trauma, unless otherwise covered by worker s compensation; Alternatives to hospital stays Outpatient surgery Eligible health services include services provided and supplies used in connection with outpatient surgery performed in a surgery center or a hospital s outpatient department. Important note: Some surgeries are done safely in a physician s office. For those surgeries, your plan will pay only for physician services and not for a separate fee for facilities. Home health care Eligible health services include home health care services provided by a home health agency in the home, but only when all of the following criteria are met: You are homebound. Your physician orders them. The services take the place of a stay in a hospital or a skilled nursing facility, or you are unable to receive the same services outside your home. The services are part of a home health care plan. HI SG HCOC GA 2018

22 The services are skilled nursing services, home health aide services or medical social services, or are short-term speech, physical or occupational therapy. Home health aide services are provided under the supervision of a registered nurse. Medical social services are provided by or supervised by a physician or social worker. If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more information on the intermittent requirement. Short-term physical, speech and occupational therapy services provided in the home are subject to the same conditions and limitations as therapy provided outside the home. See the Short-term rehabilitation services and Habilitation therapy services sections and the schedule of benefits. Home health care services do not include custodial care. Hospice care Eligible health services include inpatient and outpatient hospice care when given as part of a hospice care program. The types of hospice care services that are eligible for coverage include: Room and board Services and supplies furnished to you on an inpatient or outpatient basis Services by a hospice care agency or hospice care provided in a hospital Psychological and dietary counseling Pain management and symptom control Hospice care services provided by the providers below may be covered, even if the providers are not an employee of the hospice care agency responsible for your care: A physician for consultation or case management A physical or occupational therapist A home health care agency for: - Physical and occupational therapy - Medical supplies - Outpatient prescription drugs - Psychological counseling - Dietary counseling HI SG HCOC GA 2018

23 Skilled nursing facility Eligible health services include inpatient skilled nursing facility care. The types of skilled nursing facility care services that are eligible for coverage include: Room and board, up to the semi-private room rate Services and supplies that are provided during your stay in a skilled nursing facility For your stay in a skilled nursing facility to be eligible for coverage, the following conditions must be met: The skilled nursing facility admission will take the place of: - An admission to a hospital or sub-acute facility. - A continued stay in a hospital or sub-acute facility. There is a reasonable expectation that your condition will improve enough to go home within a reasonable amount of time. The illness or injury is severe enough to require constant or frequent skilled nursing care on a 24-hour basis. HI SG HCOC GA 2018

24 4. Emergency services and urgent care Eligible health services include services and supplies for the treatment of an emergency medical condition or an urgent condition. As always, you can get emergency services from network providers. However, you can also get emergency services from out-of-network providers. Your coverage for emergency services and urgent care from out-of-network providers ends when the attending physician and we determine that you are medically able to travel or be transported to a network provider if you need more care. Follow-up care must be provided by your physician, PCP. Follow-up care from a physician other than your PCP, like a specialist, may require a referral. See the Medical necessity and precertification requirements section for more information. In case of a medical emergency When you experience an emergency medical condition, you should go to the nearest emergency room. You can also dial 911 or your local emergency response service for medical and ambulance assistance. If possible, call your physician, but only if a delay will not harm your health. Non-emergency condition If you go to an emergency room for what is not an emergency medical condition, the plan may not cover your expenses. See the schedule of benefits and the Exceptions and Glossary sections for specific information. In case of an urgent condition Urgent condition within the service area If you need care for an urgent condition while within the service area, you should first seek care through your physician, PCP. If your physician, PCP is not reasonably available to provide services, you may access urgent care from an urgent care facility within the service area. Urgent condition outside the service area You are covered for urgent care obtained from a facility outside of the service area if you are temporarily absent from the service area and getting the health care service cannot be delayed until you return to the service area. Non-urgent care If you go to an urgent care facility for what is not an urgent condition, the plan may not cover your expenses. See the Exceptions section and the schedule of benefits for specific plan details. HI SG HCOC GA 2018

25 5. Pediatric dental care Eligible health services include dental services and supplies provided by a dental provider. The eligible health services are those listed in the pediatric dental care section of the schedule of benefits. We have grouped them as Type A, B and C, and orthodontic treatment services in the schedule of benefits. Eligible health services also include dental services provided for a dental emergency. Services and supplies provided for a dental emergency will be covered even if services and supplies are provided by an out-of-network provider. A dental emergency is any dental condition which: Occurs unexpectedly Requires immediate diagnosis and treatment in order to stabilize the condition Is characterized by symptoms such as severe pain and bleeding The plan pays a benefit up to the dental emergency maximum shown in the schedule of benefits. If you have a dental emergency, you may get treatment from any dentist. You should consider calling your network dental provider who may be more familiar with your dental needs. If you cannot reach your network dental provider or are away from home, you may get treatment from any dentist. You may also call the number on your ID card for help in finding a dentist. The care received from an out-ofnetwork provider must be for the temporary relief of the dental emergency until you can be seen by your dental provider. Services given for other than the temporary relief of the dental emergency by an out-of-network provider can cost you more. To get the maximum level of benefits, services should be provided by your network dental provider. What rules and limits apply to dental care? Several rules apply to the dental benefits. Following these rules will help you use the plan to your advantage by avoiding expenses that are not covered by the plan. When does your plan cover orthodontic treatment? Orthodontic treatment is covered for a severe, dysfunctional, disabling condition such as: Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement The following craniofacial anomalies: - Hemifacial microsomia - Craniosynostosis syndromes - Cleidocranial dental dysplasia - Arthrogryposis - Marfan syndrome Anomalies of facial bones and/or oral structures Facial trauma resulting in functional difficulties If you suffer from one of these conditions, the orthodontic services that are eligible for coverage include: Pre-orthodontic treatment visit Comprehensive orthodontic treatment Orthodontic retention (removal of appliances, construction and placement of retainers(s)) HI SG HCOC GA 2018

26 When does your plan cover replacements? The plan s replacement rule applies to: Crowns Inlays Onlays Veneers Complete dentures Removable partial dentures Fixed partial dentures (bridges) Other prosthetic services The replacement rule means that replacements of, or additions to, these dental services are covered only when: You had a tooth (or teeth) extracted after the existing denture or bridge was installed. As a result, you need to replace or add teeth to your denture or bridge. The present crown, inlay, onlay and veneer, complete denture, removable partial denture, fixed partial denture (bridge) or other prosthetic service was installed at least 5 years before its replacement and cannot be fixed. You had a tooth (or teeth) extracted. Your present denture is an immediate temporary one that replaces that tooth (or teeth). A permanent denture is needed, and the temporary denture cannot be used as a permanent denture. Replacement must occur within 12 months from the date that the temporary denture was installed. When does your plan cover missing teeth that are not replaced? The installation of complete dentures, removable partial dentures, fixed partial dentures (bridges) and other prosthetic services if: The dentures, bridges or other prosthetic items are needed to replace one or more natural teeth. (The extraction of a third molar tooth does not qualify.) The tooth that was removed was not an abutment to a removable or fixed partial denture installed during the prior 5 years. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth. An advance claim review The advance claim review gives you an idea of what we might pay for services before you receive them. Knowing this ahead of time can help you and your dental provider make informed decisions about the care you are considering. When we do the advance claim review, we will look at other procedures, services or courses of dental treatment for your dental condition. You do not have to get an advance claim review. It s voluntary. It is not necessary for emergency treatment or routine care such as cleaning teeth or check-ups. HI SG HCOC GA 2018

27 Important note: The advance claim review is not a guarantee of coverage or payment. It is an estimate. When to get an advance claim review We recommend an advance claim review when a course of dental treatment is likely to cost more than $350. Here are the steps to get an advance claim review: 1. Ask your dental provider to write down a full description of the treatment you need. To do this, they must use an Aetna claim form or an American Dental Association (ADA) approved claim form. 2. Your dental provider should send the form to us before treating you. 3. We may request supporting images and other dental records. 4. Once we have received all the information we need, we will review your dental provider s plan. We will give you and your dental provider a statement of the benefits payable. 5. You and your dental provider can then decide how to proceed. What is a course of dental treatment? A course of dental treatment is a planned program of one or more services or supplies. The services or supplies are provided by one or more dental providers to treat a dental condition. The dental condition is diagnosed by your dental provider after they have examined you. A course of treatment begins on the date your dental provider starts to correct or treat the dental condition. HI SG HCOC GA 2018

28 6. Specific conditions Autism spectrum disorder Autism spectrum disorder is defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Eligible health services include the services and supplies provided by a physician or behavioral health provider for the diagnosis and treatment of autism spectrum disorder. We will only cover the following treatment if a physician or behavioral health provider orders it as part of a treatment plan: Behavioral health treatment Habilitative and rehabilitative services Counseling services Therapy services Applied behavioral analysis Eligible health services for the treatment of autism spectrum disorder will not count toward the number of visits for the following: Physical therapy Occupational therapy Speech therapy We will cover certain early intensive behavioral interventions such as applied behavior analysis. Applied behavior analysis is an educational service that is the process of applying interventions: That systematically change behavior That are responsible for observable improvements in behavior Important note: Applied behavior analysis requires precertification by Aetna. The network provider is responsible for obtaining precertification. Diabetic equipment, supplies and education Eligible health services include: Services - Foot care to minimize the risk of infection Supplies - Diabetic needles, syringes and pens - Test strips blood glucose, ketone and urine - Injection aids for the blind - Blood glucose calibration liquid - Lancet devices and kits - Alcohol swabs Equipment - External insulin pumps and pump supplies - Blood glucose monitors without special features, unless required due to blindness HI SG HCOC GA 2018